Provider Demographics
NPI:1184958381
Name:VIGIL, SUSAN ERNESTINE (LADAC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ERNESTINE
Last Name:VIGIL
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 209
Mailing Address - Street 2:
Mailing Address - City:MORA
Mailing Address - State:NM
Mailing Address - Zip Code:87732-0209
Mailing Address - Country:US
Mailing Address - Phone:575-387-2481
Mailing Address - Fax:
Practice Address - Street 1:HWY 518 MM 26
Practice Address - Street 2:
Practice Address - City:MORA
Practice Address - State:NM
Practice Address - Zip Code:87732-0209
Practice Address - Country:US
Practice Address - Phone:575-387-2481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-22
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3936172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker